Richard Caesar Surgery

The cosmetic form of botulinum toxin, often referred to by its product name Botox®, is the most popular non-surgical cosmetic product. Delivered by injection it temporarily reduces or eliminates frown lines, forehead creases, crows feet near the eyes and thick bands in the neck. The toxin blocks the nerve impulses, temporarily paralysing the muscles that cause wrinkles, giving the skin a smoother, more refreshed appearance.The injections are usually painless, and unless you get a bruise, invisible. The Botox starts to work after the first few days and reaches maximum effect by 2 weeks. For most people Botox lasts for 3 to 4 months. As it wears off you will start to be able to frown more deeply again. By 6 months the Botox will have fully worn off. 98% choose to repeat the treatment.The popularity of Botox is such that it is available in many locations including dentists’ surgeries. The best results are achieved by surgeons and aesthetic nurses trained in the anatomy of the periocular region, and able to adjust their injections to match each individual.The pricing of Botox has typically been “per area” in the UK. The market is now becoming more sophisticated with many repeat patients becoming more and more exact in their requirements. Sometimes very little Botox is required in the additional areas, and the per area pricing does not reflect this. To give my patients better value for smaller areas I have now changed to charging per unit of Botox used. Equally if a patient then comes back for a top up, they only pay for the additional units.

What can go wrong with Botox?The risks of Botox are minimal but include:1. Bruising from the injection.2. The lateral brow peaking. This is comparatively common and is essentially an overactive frontalis muscle pulling the lateral eyebrow too high. The cure is to place a tiny amount of botox at the apex of the peak.3. A lower resting eyebrow position. This can occur when the forehead is treated to eliminate horizontal forehead lines. As the frontalis muscle is no longer pulling the eyebrows upwards they slip down into their resting position. There is a risk that this resting position is considered too low, making the upper eyelid more hooded. This risk increases with age. This risk can be minimised by reducing the Botox dose delivered to the forehead, and making sure the muscles that pull the eyebrows down are fully treated. If this eyebrow drop occurs there is unfortunately no quick fix. The Botox to the forehead will wear off and the frontalis will start to pull the eyebrows upwards again in a few weeks. The key is to use less Botox to the forehead in the future, but there is therefore an inevitable trade off between a smooth forehead with lower eyebrow, and a higher eyebrow but with more horizontal forehead lines.4. Mickey mouse smile. This occurs when the Botox at the crows feet area prevents the orbicularis muscle tightening when you smile. The deeper smile muscle that lifts the corner of your mouth then lifts your cheek against a smoother lateral eye area, generating a single deeper "mickey mouse" crease. There is no quick fix for this. The appearance will improve as the Botox wears off and the key is to use less Botox to the lower parts of the crows feet in the future.One of the reasons Botox is so popular is that there is no long term risk. The Botox effect will wear off leaving you totally back to normal in 6 months.

Botox vs Azzalure?

The market leaders for botulinum toxins have been Allergan with Botox, and Ipsen with Dysport. Botox has been so dominant that the use of botulinum toxin has become known as Botox treatment.Galderma has now brought a smaller vial of the same botulinum toxin as Dysport to the market with the trade name of Azzalure.The manufacturers obviously want to persuade us that their product is the better product. The reality, in my opinion, is that Botox, Dysport and Azzalure are all equally good. There is a subtle difference in that at the same volume of injection Dysport and Azzalure spread a little further. This is useful when treating the forehead but less useful closer to the eye. The solution when using these preparations is to use higher dose in smaller volume around the eye.In summary, I wouldn't worry which botulinum your practitoner uses so long as they are familiar with its characteristics.It is worth knowing which product you are being given, and at what dose, such that if you move to a different practitioner they know what your preferences are.